Radiotherapy

• Useful for discrete bone metastases, may be a short course or single dose
• Effective
• May be a traumatic experience – pain benefit should outweigh trauma of procedure and journey to hospital
• May require anaesthesia in very young children

NSAIDS

• Useful analgesia. Used in combination with opioids, lowers dose of opioid required for effective analgesia. A common choice is:
• Ibuprofen (see previous dosing schedule)

Steroids

There is no current evidence to suggest steroids directly bone pain in children. However they have a useful secondary effect on pain by reducing oedema and inflammation at a tumour sites. They are useful in secondary pain and headaches through reducing raised intracranial pressure or oedema/compression around nerves.

• Avoid if possible or consider short courses
• Short courses can be very effective
• Side effects include:
  • Loss of blood sugar control especially in diabetic children
  • Mood and behaviour problems
  • Weight gain and body image change
  • Reduced mobility - proximal myopathy
  • Insomnia (give entire dose before midday)
  • Dyspepsia
  • Oral/Oesophegeal candidiasis

Dexamethasone

Is the steroid of choice.

Form

Tablet: 500µg; 2mg
Oral solution: 2mg in 5mL. Other strengths available as ‘specials’.
Injection: 4mg in 1mL or 3.3mg in 1mL can be given orally.

Dose (oral/IV)

1 month -1yr: 250µg t.d.s.(max: 1mg tds)
1-5yr: 1mg t.d.s.(max 2mg tds)
6-12yr: 2mg t.d.s.(max 4mg tds)
>12yr: 4mg t.d.s.

Co-prescribing: consider antacids and anti-thrush treatment. Use in short courses to limit unwanted side effects
Caution: renal disease or cardiac disease. Avoid in cardiac insufficiency.

Licence: licensed for use in children for symptoms associated with brain tumours but not specifically for nerve pain.

Bisphosphonates

For metastatic bone disease or osteopenia

Pamidronate (IV)

Form

All ages: 1mg/kg infused over 4-6hours, repeated daily for 3 days. Can be repeated 3 monthly.
OR
All ages: 1mg/kg as a single dose infused over 4-6hr repeated monthly.

An effect on pain should be seen within 2 weeks but may need a year before definitive assessment.
May have worsening of pain at first and may experience flu-like symptoms for first few days including muscles and bone aches.
Many bisphosphonates available in different formulations, including oral. Risk of osteonecrosis only seen in adult cases, especially of jaw if pre-existing pathology.
Anecdotal risk of iatrogenic osteopetrosis with prolonged use i.e. (if prolonged use is likely, (i.e. >2 yrs) precede with DEXA scan and investigation of calcium metabolism).
IV Zoledronic acid can also be used.

Licence: Not licensed for use in children.